Provider Demographics
NPI:1386656312
Name:HARRIS, DIANE I (MD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:I
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 SEQUOIA CIR
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437-5490
Mailing Address - Country:US
Mailing Address - Phone:707-964-0259
Mailing Address - Fax:707-964-0765
Practice Address - Street 1:850 SEQUOIA CIR
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-5490
Practice Address - Country:US
Practice Address - Phone:707-964-0259
Practice Address - Fax:707-964-0765
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG44893207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G448930OtherMEDI-CAL
CA00G448930OtherMEDI-CAL
CAA06827Medicare UPIN